Innovative ACL Reconstruction: Enhancing Healing with Bone Membrane Technique - Orthopedics

Anterior cruciate ligament reconstruction

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Hello, Director Shih.
I would like to consult you again, and thank you for your response a few days ago.
Yesterday, I returned to the Tri-Service General Hospital to review my MRI report.
After examining the images, the doctor determined that I have a torn anterior cruciate ligament (ACL) that requires surgical reconstruction.
The doctor also mentioned that since my knee is still swollen, he drained the accumulated blood and advised that if there is no further swelling in two weeks, I can schedule the surgery.
He stated that it is best to perform the reconstruction within three months.
I would like to ask you, Director Shih, whether a typical ligament surgery requires hospitalization for observation.
If so, how many days would I need to stay after the surgery? Will I need to wear a brace afterward, and if so, for how long? Additionally, how long is the rehabilitation period, and when can I expect to return to my previous level of physical activity?
I also want to know where the graft is typically harvested from for the reconstruction.
I have a doctor who mentioned that in recent years, it has become increasingly popular to use the hamstring tendon autograft, which is the most commonly used autograft.
The hamstring tendon autograft involves harvesting the patient's own semitendinosus and gracilis tendons, which are folded to create a four-strand tendon graft.
This graft has sufficient strength, and the surgical incision is smaller, resulting in less postoperative anterior knee pain.
However, there is currently no widely accepted and appropriate fixation method for using the hamstring tendon as a graft.

The fixation at both ends of the graft can generally be done using interference screws, bioabsorbable interference screws, or tying sutures to screws, but each method has its potential issues and drawbacks.
Some insurance plans do not cover these, requiring out-of-pocket expenses.
Additionally, the healing of the graft tendon to the bone must be considered.
Therefore, finding a simple and effective method to enhance the healing of the hamstring tendon graft within the bone tunnel post-reconstruction is a significant concern for clinicians.
To address this issue, we have recently innovated a new method by wrapping a layer of cortical bone tissue around the tendon, utilizing the potential of the periosteum to promote healing between the graft and bone within the tunnel.

In our basic research, supported by the National Science Council, we used rabbits as an experimental animal model to study the histological and biomechanical aspects of healing with the cortical bone wrapping.
The results showed that by the fourth week, in the periosteum group, bone ingrowth was observed in the fibrous layer tissue separating the tendon and bone tunnel, with the periosteum interdigitating with the tendon.
By the eighth week, the ingrown bone and cortical layer became more mature and organized, further integrating.
By the twelfth week, fibrous cartilage formation was evident in the cortical fibrous layer, and the tendon and bone had completely healed, forming a robust tissue.
Biomechanical testing results indicated that interface strength increased significantly over time, with the eighth week showing greater strength than the fourth week, and the twelfth week showing greater strength than the eighth week.
At the fourth week, the interface strength was greater in the periosteum group compared to the non-periosteum group.
At the eighth and twelfth weeks, the periosteum group also showed significant increases compared to the non-periosteum group.
In clinical applications, since the periosteum contains various potential mesenchymal stem cells, it has the ability to form various connective tissues, including cartilage and bone.
Suturing the periosteum around the tendon and then implanting it into the bone tunnel has been shown to promote tendon-bone healing.
The results of this study have received positive recognition and awards at international conferences.

Since 2000, we have been applying this technique in arthroscopic ACL reconstruction surgeries.
When we reconstruct the ACL using the hamstring tendon, we wrap the periosteum around the tendon graft to promote early healing of the tendon-bone interface within the bone tunnel.
Clinical follow-up results have been quite satisfactory.
In conclusion, arthroscopic ACL reconstruction is one of the fastest-developing surgical techniques in orthopedics over the past decade.
The surgery is quick, minimally invasive, and can significantly reduce patient discomfort.
With proactive rehabilitation training post-surgery, patients can typically return to daily activities within three months, engage in light sports around six months, and regain pre-injury levels of activity within nine to twelve months.
This method not only accelerates the healing of the newly transplanted ligament to the bone but also simplifies the surgical procedure, makes obtaining the periosteum easier, avoids additional incisions, and does not require out-of-pocket expenses for special fixation devices, yielding very satisfactory clinical results.
I would appreciate any suggestions you might have, as I truly hope to continue my athletic activities after the surgery.
Thank you, Director Shih.

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Vic, 20~29 year old female. Ask Date: 2005/08/09